When a Child Is Hospitalized with COVID

Sometime long ago—in early 2020—an infection-prevention specialist came to morning report to review personal protective equipment with the pediatricians at the hospital in San Antonio where I work. She laid out a gown, gloves, an N95 mask, and a face shield on the table in front of us, then called for a volunteer to practice donning the P.P.E. This was when morning report was a physical gathering in a room, with breakfast tacos. We would all sit elbow to elbow, listening to a lecture on new treatment protocols for sick children, or discussing a recent challenging case. Our terrifying human faces were exposed to the communal air, and we put tacos into them and breathed out of them as if such things—the tacos, the breathing—did not pose existential threats. Now, of course, there are no large gatherings at the hospital, and there is no shared food, and I have trainees I’ve worked closely with for more than a year who have never seen the bottom of my face. I miss the tacos and the gatherings; fifty smart people all thinking about a sick child together is one of the most beautiful parts of medicine, I think. But I like the little shock of the uncanny when someone pulls off a mask to drink and I see the shape of their chin.

At the beginning of the pandemic, nurses or techs would be stationed outside the COVID rooms to watch us don and doff the P.P.E. (I enjoy the phrase “don and doff,” which makes me feel like a duchess of the respiratory virus.) Even in non-pandemic times, hospital pediatricians often wear P.P.E.—our patients are likely to scream, cry, or vomit at any moment, and so they produce many aerosolized particles. And respiratory viruses have long been a common reason for hospital admission for people with tiny noses and lungs.

The virus felt paranormal when it first arrived. I was pregnant, and my colleagues spared me from seeing known coronavirus patients. They saw them for me, which seemed like they were risking death on behalf of my baby and me. They did it without ever making me feel bad, and I was grateful and remain grateful to be in a specialty in which living in a woman-shaped body or a pregnant body does not seem to make one less of a physician. Indeed, my patients and colleagues warmed to me as my belly swelled; I bore signs of life in pandemic times. I delivered my son, Sam, at what we thought would be the height of the crisis. On the day Sam was born, Bexar County announced nine hundred and forty-six new cases of COVID and twenty-four new deaths. (Of course, we were wrong about the peak; the county averaged more than a thousand cases a day this past August.) When I returned to work from maternity leave and began seeing patients known to have the coronavirus, I felt a special tenderness for the techs and nurses who would watch me don and doff. I would bow my head on exiting a COVID room so another woman—almost always, it was a woman—could remove my face shield, disinfect it with a CaviWipe, and send me on my way. I felt comforted and kept, just as I had when nurses cared for me during Sam’s delivery.

Now we know that SARS-CoV-2 isn’t paranormal—it isn’t a miasma floating through the hallways or a trickster who sneaks through P.P.E. If you have the equipment you need, and you use it correctly, you are likely to stay safe. I feel safer at the hospital than I do at the grocery store. Now the hospital staff is mostly vaccinated; now I whip in and out of P.P.E with nobody watching. I walk from a room where the air is soupy with coronavirus and I do not worry that the virus travels with me. You’re not so novel now, are you, coronavirus?

There are many COVID rooms right now, in children’s hospitals across the nation and particularly here in Texas. After the Delta variant began circulating, the number of children admitted with COVID nearly quintupled. I linger in these rooms sometimes, just getting to know my patients. In the beginning, that would have felt profoundly foolish—to risk exposure to the virus simply to know what this teen-ager plans to do when she finishes high school, or if that kindergartner has a favorite animal. (Dolphins and cheetahs remain popular among outgoing children; house cats are preferred by the shy.) I will not regret the choices that I’ve made or the care that I have given to others if I become infected myself, but I will regret it all if I transmit the coronavirus to my own unvaccinated child.

In Texas, the highly contagious Delta variant came to dominate the epidemiological landscape just before school-age kids returned to in-person learning. Governor Greg Abbott has battled to prevent local public-health officials from mandating mask wearing, even in crowded indoor spaces such as schools, where a large cohort of unvaccinated Americans has gathered. The American Academy of Pediatrics has reported that kids currently represent a significantly higher percentage of known coronavirus cases than they have previously; during the entire course of the pandemic, 15.7 per cent of COVID cases have been among children, but in mid-September almost twenty-six per cent of new diagnoses were among children. Still, over-all rates of hospitalization among kids remain low. On September 21st, the Texas Department of State Health Services listed two hundred and fifty-three children in Texas hospitals with COVID, out of a total of more than eleven thousand six hundred hospitalized coronavirus patients in the state.

Hospital care for children does not occur in isolation from that of adults. Many of the resources we use are the same—a twenty-pound baby and a two-hundred-pound man might use the same kind of ventilator, for example. Dialysis machines, which could cleanse a seven-year-old’s blood as easily as his grandfather’s, are in high demand. Pediatric resident physicians, nurses, and respiratory therapists get cross-deployed to care for adults during the surges. I’m unaware of any American child who has been reported to have died of COVID because of a lack of technological resources in hospitals; even now, a hundred and fourteen staffed pediatric I.C.U. beds are available in the state of Texas. But it is worth noting that when hospitals fill with adults, children can be affected, too.

Among people under age eighteen, the risk of being hospitalized after catching SARS-CoV-2 is higher for babies and teen-agers than it is for elementary-age kids. Among all youth, teen-agers are most likely to die of COVID-19. The patients whom my colleagues and I are seeing fall roughly into four groups. There is a smattering of sick babies who need oxygen. (Often, they have COVID and another virus or two simultaneously, or they have had multiple viruses so recently that our test can still detect them.) We have a few teen-agers who have prolonged respiratory failure—they need oxygen for many days or weeks, and wean off slowly until they can walk around the room for six whole minutes without their oxygen levels dropping, and then we send them home. We have kids who came into the hospital for something else and were incidentally found to be COVID positive. And, finally, we see kids with unusual complications of COVID, such as a stroke, a blood clot in the lungs, or MIS-C—the dangerous inflammatory syndrome that occurs after infection in about one in every thirty-two hundred infected children. D.S.H.S. has confirmed two hundred and thirty-one cases of MIS-C in Texas. We anticipate more this fall, as kids who were infected during the Delta surge will develop the post-infectious complication a few weeks later.

What we are not seeing, thank God, is the rampant death that our adult-medicine colleagues have witnessed. Nationwide, five hundred and forty-four pediatric COVID deaths have been reported to the C.D.C. since the beginning of the pandemic. Adult death by coronavirus has accumulated its own heartbreaking and grim clichés: the last few words with family before intubation, often exchanged via iPad; the daily phone updates saying that nothing has changed, until suddenly it does; the fact that you won’t die strictly alone because the nurse or doctor or respiratory therapist will be there and will hold your hand while you go. Pediatric death by COVID has no such commonplaces; it is rare enough to rattle us, as children’s deaths almost always do.

On any given afternoon in the hospital, my team might be called down to the E.R. to see a child who is having trouble breathing—and that is so much of what hospital pediatricians oversee that the coronavirus cases do not feel so different from others. By the time a child arrives in the E.R., the parents have generally done everything they can at home: some mixture of suction, Tylenol, hot baths, cool baths, humidifiers, herbs, prayer, and crystals, depending on the family. But the kid stopped making wet diapers, or couldn’t catch her breath long enough to eat or sleep, or just looked bad, so they hauled her in. I will stand in the doorway and watch the child awhile. There may be lab tests, X-rays, or vital signs to go over. But, in most cases, I will know whether the baby needs me just by looking at her—the quickness of her breathing, the panicky look in her eyes, the way her shoulders shrug and her head bobs slightly with each inhalation.

Lingering in the room, I will ask parents to tell me about the kid, what she is usually like. The details about small children are sweetly generic—that she smiles a lot, or she has strong opinions, or she is always chasing her big brothers around. I ask about nicknames, and learn that one baby goes by Papi Chulo and another by the Queen. I will nod and say, “O.K. That’s what we’re hoping to see. It may take some time, but we’re hoping to get little Papi Chulo here back to chasing his brothers around.”

The coronavirus is uniquely frightening to parents. (My kid has been tested once, and I cried all the way to the clinic. It was negative—he had roseola, and for a week his nickname became Mr. Spots.) At a frequency slightly higher than what I see with other admissions, parents ask whether their kid is going to die. It’s tempting to say no, to grab their hands and swear that the kid will live, but I don’t do that. Once a kid is sick enough with COVID to require hospitalization, current data suggest that about one in a hundred will not survive. I hedge a little and say, “Most children her age with pneumonia from COVID get all the way better with just a little support from oxygen or fluids. We will watch her very closely. If she is not getting better, or if she gets sicker, we will talk to our I.C.U. doctors to help us give her more support.” I convey hope and confidence, but I don’t make any promises.

At least, I don’t make the promise they want. Instead, I promise to be honest. I promise that my team is in the hospital twenty-four hours a day, usually in that room just down the hall. I promise to care for each child just as I would want my own son to be cared for. Sam—my Squanch, my little Samwich. He smiles a lot, and is always chasing the cat around. Like every other American under the age of twelve, he is not yet eligible for the COVID vaccine.

Between a quarter and a third of kids hospitalized with COVID wind up in the I.C.U., but less than ten per cent are put on a ventilator. The best data we have suggest that the pediatric death rate from Delta is similar to that from earlier variants—that is, exceedingly rare. But survival promises are bad luck; they are partly wishes, and, by hospital magic, saying them aloud makes them less likely to come true. Even so, wishes fly thick in this air. Parents wish to take away their child’s illness; they wish to take the place of a suffering child. It never fails to bring me to tears when a parent leans over the hospital crib and says, “It should be me, not her.”

In part because I work at a trauma hospital, much of what I see all the time is preventable: gun injuries, burns, children thrown from automobiles. Sometimes, life-changing pediatric injury follows blatant foolishness, like parents allowing the six-year-old to drive the golf cart. But sometimes it is of a moment: Grandma places microwaved noodle soup too close to the edge of a counter, and the baby pulls it down on her own face. Pediatric coronavirus infections seem to be somewhere in the middle: preventable in an ideal world, but hard for even the most scrupulous parents to avoid when state governments have tied the hands of health officials. Many of the parents I see lately at the bedsides of infected children are themselves infected. Their heads hurt and they are coughing. They pull on masks when I come into the room, which is polite. We do not yet know what percentage of children are catching it from unvaccinated adult family members (or how many adults or kids are catching it from unvaccinated children at school). But we do know that the home—that space which should be safest, where we bow our heads together and sleep in a tangle—is a most efficient place to spread the coronavirus.

Sometimes parents ask what they should have done differently. I keep my promise to be honest even when I sense that parents are asking me for absolution. There are things these parents could’ve done: surround their children with vaccinated adults, wear masks, exhibit caution about gathering in groups. But there is also systemic injustice placing some kids at higher risk, and there is simple virulence: we open our doors for a moment and the killer pushes through the screen. At that moment when a small child is struggling to breathe, most parents have leaped far ahead of me in self-recrimination. I try not to make them suffer any more.

Soon there will be another way to protect younger kids: the coronavirus vaccine is likely to be approved for children age five and up this year. I love being a hospital pediatrician, but no family wants to have a need for the care I provide. Vaccinating your children is a way to insure that we never meet.

I go home when the children are accounted for, and my team of resident doctors stays all night caring for them. In the morning, I might come in to find that one of my teen-age patients is finally off oxygen, and I will grin in the hallway as I pull on the P.P.E. (“Amazing,” he says, when I ask how he is feeling.) I might go by and wean Papi Chulo’s oxygen, or turn it up a bit. We are busy just now, but thankfully it is not so very different from any other season in a children’s hospital. Everybody just needs a little bit of help to breathe.